Sections

DDx

Diagnostic Considerations

The differential diagnoses of urinary incontinence are broad, with multiple causes. Sometimes, more than one contributing factor exists, further complicating diagnosis and therapy. Distinguishing these different etiologies is imperative because each condition warrants a different, but often overlapping, therapeutic approach.

Differential Diagnoses

Workup

[Guideline] Russo E, Caretto M, Giannini A, Bitzer J, Cano A, Ceausu I, et al. Management of urinary incontinence in postmenopausal women: An EMAS clinical guide. Maturitas. 2021 Jan. 143:223-230. [QxMD MEDLINE Link].
Erdem N, Chu FM. Management of overactive bladder and urge urinary incontinence in the elderly patient. Am J Med. 2006 Mar. 119(3 Suppl 1):29-36. [QxMD MEDLINE Link].
Vaughan CP, Markland AD. Urinary Incontinence in Women. Ann Intern Med. 2020 Feb 4. 172 (3):ITC17-ITC32. [QxMD MEDLINE Link].
[Guideline] American College of Obstetricians and Gynecologists. Practice Bulletin No. 155: Urinary Incontinence in Women. Obstet Gynecol. 2016 May. 127 (5):e66-81. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. 2008 Mar 6. 358(10):1029-36. [QxMD MEDLINE Link].
Rehder P, Haab F, Cornu JN, Gozzi C, Bauer RM. Treatment of Postprostatectomy Male Urinary Incontinence With the Transobturator Retroluminal Repositioning Sling Suspension: 3-Year Follow-up. Eur Urol. 2012 Feb 25. [QxMD MEDLINE Link].
Serati M, Braga A, Cattoni E, Siesto G, Cromi A, Ghezzi F, et al. Transobturator vaginal tape for the treatment of stress urinary incontinence in elderly women without concomitant pelvic organ prolapse: is it effective and safe?. Eur J Obstet Gynecol Reprod Biol. 2013 Jan. 166(1):107-10. [QxMD MEDLINE Link].
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002. 21(2):167-78. [QxMD MEDLINE Link].
Chutka DS, Fleming KC, Evans MP, Evans JM, Andrews KL. Urinary incontinence in the elderly population. Mayo Clin Proc. 1996 Jan. 71(1):93-101. [QxMD MEDLINE Link].
Gibbs CF, Johnson TM 2nd, Ouslander JG. Office management of geriatric urinary incontinence. Am J Med. 2007 Mar. 120(3):211-20. [QxMD MEDLINE Link].
McFall S, Yerkes AM, Bernard M, LeRud T. Evaluation and treatment of urinary incontinence. Report of a physician survey. Arch Fam Med. 1997 Mar-Apr. 6(2):114-9. [QxMD MEDLINE Link].
Wallner LP, Porten S, Meenan RT, O'Keefe Rosetti MC, Calhoun EA, Sarma AV, et al. Prevalence and severity of undiagnosed urinary incontinence in women. Am J Med. 2009 Nov. 122(11):1037-42. [QxMD MEDLINE Link]. [Full Text].
Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol. 1997 Dec. 104(12):1374-9. [QxMD MEDLINE Link].
Abrams P, Cardozo L, Khoury S, et al, Eds. Incontinence. 4th ed. Paris, France: Health Publication Ltd; 2009. Chapter 5B.
Delancey JO, Ashton-Miller JA. Pathophysiology of adult urinary incontinence. Gastroenterology. 2004 Jan. 126(1 Suppl 1):S23-32. [QxMD MEDLINE Link].
Dietz HP, Wilson PD. Anatomical assessment of the bladder outlet and proximal urethra using ultrasound and videocystourethrography. Int Urogynecol J Pelvic Floor Dysfunct. 1998. 9(6):365-9. [QxMD MEDLINE Link].
Chaikin DC, Groutz A, Blaivas JG. Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse. J Urol. 2000 Feb. 163(2):531-4. [QxMD MEDLINE Link].
Mills IW, Greenland JE, McMurray G, McCoy R, Ho KM, Noble JG, et al. Studies of the pathophysiology of idiopathic detrusor instability: the physiological properties of the detrusor smooth muscle and its pattern of innervation. J Urol. 2000 Feb. 163(2):646-51. [QxMD MEDLINE Link].
Wein AJ, Rackley RR. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. J Urol. 2006 Mar. 175(3 Pt 2):S5-10. [QxMD MEDLINE Link].
Kinder RB, Mundy AR. Pathophysiology of idiopathic detrusor instability and detrusor hyper-reflexia. An in vitro study of human detrusor muscle. Br J Urol. 1987 Dec. 60(6):509-15. [QxMD MEDLINE Link].
Cukier JM, Cortina-Borja M, Brading AF. A case-control study to examine any association between idiopathic detrusor instability and gastrointestinal tract disorder, and between irritable bowel syndrome and urinary tract disorder. Br J Urol. 1997 Jun. 79(6):865-78. [QxMD MEDLINE Link].
Tse V, Wills E, Szonyi G, Khadra MH. The application of ultrastructural studies in the diagnosis of bladder dysfunction in a clinical setting. J Urol. 2000 Feb. 163(2):535-9. [QxMD MEDLINE Link].
Elbadawi A, Yalla SV, Resnick NM. Structural basis of geriatric voiding dysfunction. III. Detrusor overactivity. J Urol. 1993 Nov. 150(5 Pt 2):1668-80. [QxMD MEDLINE Link].
Chughtai B, Forde JC, Thomas DD, Laor L, Hossack T, Woo HH, et al. Benign prostatic hyperplasia. Nat Rev Dis Primers. 2016 May 5. 2:16031. [QxMD MEDLINE Link].
Litwiller SE, Frohman EM, Zimmern PE. Multiple sclerosis and the urologist. J Urol. 1999 Mar. 161(3):743-57. [QxMD MEDLINE Link].
Patel AK, Chapple CR. Urodynamics in the management of female stress incontinence--which test and when?. Curr Opin Urol. 2008 Jul. 18(4):359-64. [QxMD MEDLINE Link].
Petros PE, Woodman PJ. The Integral Theory of continence. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Jan. 19(1):35-40. [QxMD MEDLINE Link].
Crankson SJ, Ahmed S. Female bladder exstrophy. Int Urogynecol J Pelvic Floor Dysfunct. 1997. 8(2):98-104. [QxMD MEDLINE Link].
Wojcik LJ, Kaplan GW. The wet child. Urol Clin North Am. 1998 Nov. 25(4):735-44, xi. [QxMD MEDLINE Link].
Steele AC, Kohli N, Mallipeddi P, Karram M. Pharmacologic causes of female incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1999. 10(2):106-10. [QxMD MEDLINE Link].
Morgan JL, O'Connell HE, McGuire EJ. Is intrinsic sphincter deficiency a complication of simple hysterectomy?. J Urol. 2000 Sep. 164(3 Pt 1):767-9. [QxMD MEDLINE Link].
Castellan P, Ferretti S, Litterio G, Marchioni M, Schips L. Management of Urinary Incontinence Following Radical Prostatectomy: Challenges and Solutions. Ther Clin Risk Manag. 2023. 19:43-56. [QxMD MEDLINE Link]. [Full Text].
Wilson MM. Urinary incontinence: selected current concepts. Med Clin North Am. 2006 Sep. 90(5):825-36. [QxMD MEDLINE Link].
Vaughan CP, Tangpricha V, Motahar-Ford N, Goode PS, Burgio KL, Allman RM, et al. Vitamin D and incident urinary incontinence in older adults. Eur J Clin Nutr. 2016 Sep. 70 (9):987-9. [QxMD MEDLINE Link]. [Full Text].
Cummings JM, Rodning CB. Urinary stress incontinence among obese women: review of pathophysiology therapy. Int Urogynecol J Pelvic Floor Dysfunct. 2000. 11(1):41-4. [QxMD MEDLINE Link].
Sustersic O, Kralj B. The influence of obesity, constitution and physical work on the phenomenon of urinary incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct. 1998. 9(3):140-4. [QxMD MEDLINE Link].
Lai HH, Helmuth ME, Smith AR, Wiseman JB, Gillespie BW, Kirkali Z, et al. Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence Among Male and Female Patients Seeking Care for Their Lower Urinary Tract Symptoms. Urology. 2018 Oct 28. [QxMD MEDLINE Link].
Mishra GD, Barker MS, Herber-Gast GC, Hillard T. Depression and the incidence of urinary incontinence symptoms among young women: Results from a prospective cohort study. Maturitas. 2015 Aug. 81 (4):456-61. [QxMD MEDLINE Link].
Lenherr SM, Clemens JQ, Braffett BH, Dunn RL, Cleary PA, Kim C, et al. Glycaemic control and risk of incident urinary incontinence in women with Type 1 diabetes: results from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study. Diabet Med. 2016 Nov. 33 (11):1528-1535. [QxMD MEDLINE Link].
Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am. 2001 Aug. 19(3):591-619. [QxMD MEDLINE Link].
Al-Mukhtar Othman J, Åkervall S, Milsom I, Gyhagen M. Urinary incontinence in nulliparous women aged 25-64 years - A national survey. Am J Obstet Gynecol. 2016 Oct 6. [QxMD MEDLINE Link].
Howard D, Delancey JO, Tunn R, Ashton-Miller JA. Racial differences in the structure and function of the stress urinary continence mechanism. Obstet Gynecol. 2000 May. 95(5):713-7. [QxMD MEDLINE Link]. [Full Text].
Linde JM, Nijman RJ, Trzpis M, Broens PM. Urinary incontinence in the Netherlands: Prevalence and associated risk factors in adults. Neurourol Urodyn. 2016 Oct 4. [QxMD MEDLINE Link].
Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. 300(11):1311-6. [QxMD MEDLINE Link]. [Full Text].
Fultz NH, Herzog AR, Raghunathan TE, Wallace RB, Diokno AC. Prevalence and severity of urinary incontinence in older African American and Caucasian women. J Gerontol A Biol Sci Med Sci. 1999 Jun. 54(6):M299-303. [QxMD MEDLINE Link].
Anger JT, Saigal CS, Litwin MS. The prevalence of urinary incontinence among community dwelling adult women: results from the National Health and Nutrition Examination Survey. J Urol. 2006 Feb. 175(2):601-4. [QxMD MEDLINE Link].
Freeman EW, Grisso JA, Berlin J, Sammel M, Garcia-Espana B, Hollander L. Symptom reports from a cohort of African American and white women in the late reproductive years. Menopause. 2001 Jan-Feb. 8(1):33-42. [QxMD MEDLINE Link].
Sears CL, Wright J, O'Brien J, Jezior JR, Hernandez SL, Albright TS, et al. The racial distribution of female pelvic floor disorders in an equal access health care system. J Urol. 2009 Jan. 181(1):187-92. [QxMD MEDLINE Link].
Daneshgari F, Imrey PB, Risendal B, Dwyer A, Barber MD, Byers T. Differences in urinary incontinence between Hispanic and non-Hispanic white women: a population-based study. BJU Int. 2008 Mar. 101(5):575-9. [QxMD MEDLINE Link].
Castillo PA, Espaillat-Rijo LM, Davila GW. Outcome measures and definition of cure in female stress urinary incontinence surgery: a survey of recent publications. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Mar. 21(3):343-8. [QxMD MEDLINE Link].
Foley AL, Loharuka S, Barrett JA, et al. Association between the Geriatric Giants of urinary incontinence and falls in older people using data from the Leicestershire MRC Incontinence Study. Age Ageing. 2012 Jan. 41(1):35-40. [QxMD MEDLINE Link].
[Guideline] O'Reilly N, Nelson HD, Conry JM, Frost J, Gregory KD, Kendig SM, et al. Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative. Ann Intern Med. 2018 Sep 4. 169 (5):320-328. [QxMD MEDLINE Link]. [Full Text].
Nygaard I, Holcomb R. Reproducibility of the seven-day voiding diary in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2000. 11(1):15-7. [QxMD MEDLINE Link].
Dupont MC, Albo ME, Raz S. Diagnosis of stress urinary incontinence. An overview. Urol Clin North Am. 1996 Aug. 23(3):407-15. [QxMD MEDLINE Link].
Fedorkow DM, Sand PK, Retzky SS, Johnson DC. The cotton swab test. Receiver-operating characteristic curves. J Reprod Med. 1995 Jan. 40(1):42-6. [QxMD MEDLINE Link].
Miller JM, Ashton-Miller JA, Delancey JO. Quantification of cough-related urine loss using the paper towel test. Obstet Gynecol. 1998 May. 91(5 Pt 1):705-9. [QxMD MEDLINE Link].
Swift SE, Yoon EA. Test-retest reliability of the cough stress test in the evaluation of urinary incontinence. Obstet Gynecol. 1999 Jul. 94(1):99-102. [QxMD MEDLINE Link].
Summitt RL Jr, Stovall TG, Bent AE, Ostergard DR. Urinary incontinence: correlation of history and brief office evaluation with multichannel urodynamic testing. Am J Obstet Gynecol. 1992 Jun. 166(6 Pt 1):1835-40; discussion 1840-4. [QxMD MEDLINE Link].
Jensen JK, Nielsen FR Jr, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol. 1994 May. 83(5 Pt 2):904-10. [QxMD MEDLINE Link].
Amundsen CL, Richter HE, Menefee S, Vasavada S, Rahn DD, Kenton K, et al. The Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment: ROSETTA trial. Contemp Clin Trials. 2014 Mar. 37 (2):272-83. [QxMD MEDLINE Link]. [Full Text].
Duthie JB, Vincent M, Herbison GP, Wilson DI, Wilson D. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database Syst Rev. 2011 Dec 7. CD005493. [QxMD MEDLINE Link].
Petros PE. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int Urogynecol J Pelvic Floor Dysfunct. 1997. 8(5):270-7. [QxMD MEDLINE Link].
Balk EM, Rofeberg VN, Adam GP, Kimmel HJ, Trikalinos TA, Jeppson PC. Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes. Ann Intern Med. 2019 Mar 19. [QxMD MEDLINE Link].
Moore KN, Schieman S, Ackerman T, Dzus HY, Metcalfe JB, Voaklander DC. Assessing comfort, safety, and patient satisfaction with three commonly used penile compression devices. Urology. 2004 Jan. 63(1):150-4. [QxMD MEDLINE Link].
Lee DI, Wedmid A, Mendoza P, et al. Bladder Neck Plication Stitch: A Novel Technique During Robot-Assisted Radical Prostatectomy to Improve Recovery of Urinary Continence. J Endourol. 2011 Sep 23. [QxMD MEDLINE Link].
Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998 Sep. 105(3):236-41. [QxMD MEDLINE Link].
Schuessler B. What do we know about duloxetine's mode of action? Evidence from animals to humans. BJOG. 2006 May. 113 Suppl 1:5-9. [QxMD MEDLINE Link].
Cardozo L, Drutz HP, Baygani SK, Bump RC. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Obstet Gynecol. 2004 Sep. 104(3):511-9. [QxMD MEDLINE Link].
Duckett JR, Aggarwal I, Patil A. Duloxetine treatment for women awaiting continence surgery. Int Urogynecol J Pelvic Floor Dysfunct. Nov 2006;17(6):563-5.
Cardozo L, Lange R, Voss S, Beardsworth A, Manning M, Viktrup L, et al. Short- and long-term efficacy and safety of duloxetine in women with predominant stress urinary incontinence. Curr Med Res Opin. 2010 Feb. 26(2):253-61. [QxMD MEDLINE Link].
Appell RA, Sand P, Dmochowski R, Anderson R, Zinner N, Lama D, et al. Prospective randomized controlled trial of extended-release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: results of the OBJECT Study. Mayo Clin Proc. 2001 Apr. 76(4):358-63. [QxMD MEDLINE Link].
Nazir J, Kelleher C, Aballéa S, Maman K, Hakimi Z, Mankowski C, et al. Comparative efficacy and tolerability of solifenacin 5 mg/day versus other oral antimuscarinic agents in overactive bladder: A systematic literature review and network meta-analysis. Neurourol Urodyn. 2018 Mar. 37 (3):986-996. [QxMD MEDLINE Link].
Steers W, Corcos J, Foote J, Kralidis G. An investigation of dose titration with darifenacin, an M3-selective receptor antagonist. BJU Int. 2005 Mar. 95 (4):580-6. [QxMD MEDLINE Link]. [Full Text].
Serra DB, Affrime MB, Bedigian MP. QT and QTc interval with standard and supratherapeutic doses of darifenacin, a muscarinic M3 selective receptor antagonist for the treatment of overactive bladder. J Clin Pharmacol. Sep 2005;45(9):1038-47.
Gordon D, Groutz A, Ascher-Landsberg J, Lessing JB, David MP, Razz O. Double-blind, placebo-controlled study of magnesium hydroxide for treatment of sensory urgency and detrusor instability: preliminary results. Br J Obstet Gynaecol. 1998 Jun. 105 (6):667-9. [QxMD MEDLINE Link].
[Guideline] Gormley EA, Lightner DJ, Faraday M, Vasavada SP, American Urological Association, Society of Urodynamics, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol. 2015 May. 193 (5):1572-80. [QxMD MEDLINE Link]. [Full Text].
Staskin D, Frankel J, Varano S, Shortino D, Jankowich R, Mudd PN Jr. International Phase III, Randomized, Double-Blind, Placebo and Active Controlled Study to Evaluate the Safety and Efficacy of Vibegron in Patients with Symptoms of Overactive Bladder: EMPOWUR. J Urol. 2020 Aug. 204 (2):316-324. [QxMD MEDLINE Link].
Staskin D, Frankel J, Varano S, Shortino D, Jankowich R, Mudd PN Jr. Once-Daily Vibegron 75 mg for Overactive Bladder: Long-Term Safety and Efficacy From a Double-Blind Extension Study of the International Phase 3 Trial (EMPOWUR). J Urol. 2020 Dec 28. 101097JU0000000000001574. [QxMD MEDLINE Link].
Grady D, Brown JS, Vittinghoff E, Applegate W, Varner E, Snyder T. Postmenopausal hormones and incontinence: the Heart and Estrogen/Progestin Replacement Study. Obstet Gynecol. 2001 Jan. 97(1):116-20. [QxMD MEDLINE Link].
Hendrix SL, Cochrane BB, Nygaard IE, Handa VL, Barnabei VM, Iglesia C, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA. 2005 Feb 23. 293(8):935-48. [QxMD MEDLINE Link].
Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev. 2012 Oct 17. 10:CD001405. [QxMD MEDLINE Link].
Herschorn S, Gajewski J, Ethans K, Corcos J, Carlson K, Bailly G, et al. Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial. J Urol. 2011 Jun. 185(6):2229-35. [QxMD MEDLINE Link].
Cruz F, Herschorn S, Aliotta P, Brin M, Thompson C, Lam W, et al. Efficacy and Safety of OnabotulinumtoxinA in Patients with Urinary Incontinence Due to Neurogenic Detrusor Overactivity: A Randomised, Double-Blind, Placebo-Controlled Trial. Eur Urol. 2011 Jul 13. [QxMD MEDLINE Link].
Ginsberg D, et al. Phase 3 Efficacy and Safety Study of OnabotulinumtoxinA in Patients With Urinary Incontinence Due to Neurogenic Detrusor Overactivity. Presented at 107th Annual Meeting of the American Urological Association, Washington, DC. May, 2011.
FDA approves Botox to treat overactive bladder. U.S. Food & Drug Administration. Available at https://wayback.archive-it.org/7993/20170112032338/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm336101.htm. January 8, 2013; Accessed: May 26, 2023.
Visco AG, Brubaker L, Richter HE, Nygaard I, Paraiso MF, Menefee SA, et al. Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. N Engl J Med. 2012 Nov 8. 367(19):1803-13. [QxMD MEDLINE Link].
Amundsen CL, Richter HE, Menefee SA, Komesu YM, Arya LA, Gregory WT, et al. OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. JAMA. 2016 Oct 4. 316 (13):1366-1374. [QxMD MEDLINE Link].
Charles W Nager 1, Linda Brubaker, Heather J Litman, Halina M Zyczynski, R Edward Varner, Cindy Amundsen, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012 May 24. 366 (21):1987-97. [QxMD MEDLINE Link]. [Full Text].
Honda M, Kimura Y, Tsounapi P, Hikita K, Saito M, Takenaka A. Long-Term Efficacy, Safety, and Tolerability of Modified Intravesical Oxybutynin Chloride for Neurogenic Bladder in Children. J Clin Med Res. 2019 Apr. 11 (4):256-260. [QxMD MEDLINE Link]. [Full Text].
Krause P, Fuhr U, Schnitker J, Albrecht U, Stein R, Rubenwolf P. Pharmacokinetics of intravesical versus oral oxybutynin in healthy adults: results of an open label, randomized, prospective clinical study. J Urol. 2013 Nov. 190 (5):1791-7. [QxMD MEDLINE Link].
Chancellor MB, de Groat WC. Intravesical capsaicin and resiniferatoxin therapy: spicing up the ways to treat the overactive bladder. J Urol. 1999 Jul. 162(1):3-11. [QxMD MEDLINE Link].
De Ridder D, Chandiramani V, Dasgupta P, Van Poppel H, Baert L, Fowler CJ. Intravesical capsaicin as a treatment for refractory detrusor hyperreflexia: a dual center study with long-term followup. J Urol. 1997 Dec. 158 (6):2087-92. [QxMD MEDLINE Link].
Dasgupta P. Capsaicin, resiniferatoxin and botulinum toxin-A – a trip down memory lane. BJU Int. 2015 May. 115 (5):675. [QxMD MEDLINE Link]. [Full Text].
Kuismanen K, Sartoneva R, Haimi S, et al. Autologous adipose stem cells in treatment of female stress urinary incontinence: results of a pilot study. Stem Cells Transl Med. 2014 Jul 1. [QxMD MEDLINE Link].
Katz EG, MacLachlan LS. Nocturnal Enuresis in the Adult. Curr Urol Rep. 2020 Jun 6. 21 (8):31. [QxMD MEDLINE Link].
Gomez Rincon M, Leslie SW, Lotfollahzadeh S. Nocturnal Enuresis. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009 Apr 2. 360(14):1429-36. [QxMD MEDLINE Link].
[Guideline] Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Sep 16. 161 (6):429-40. [QxMD MEDLINE Link]. [Full Text].
Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018 Oct 4. 10:CD005654. [QxMD MEDLINE Link].
Goode PS, Burgio KL, Johnson TM 2nd, Clay OJ, Roth DL, Markland AD, et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA. 2011 Jan 12. 305(2):151-9. [QxMD MEDLINE Link].
Sjöström M, Umefjord G, Stenlund H, Carlbring P, Andersson G, Samuelsson E. Internet-based treatment of stress urinary incontinence: 1- and 2-year results of a randomized controlled trial with a focus on pelvic floor muscle training. BJU Int. 2015 Feb 14. [QxMD MEDLINE Link].
Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, et al. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA. 2019 Sep 17. 322 (11):1066-1076. [QxMD MEDLINE Link].
Paik SH, Han SR, Kwon OJ, Ahn YM, Lee BC, Ahn SY. Acupuncture for the treatment of urinary incontinence: A review of randomized controlled trials. Exp Ther Med. 2013 Sep. 6 (3):773-780. [QxMD MEDLINE Link]. [Full Text].
Liu Z, Liu Y, Xu H, He L, Chen Y, Fu L, et al. Effect of Electroacupuncture on Urinary Leakage Among Women With Stress Urinary Incontinence: A Randomized Clinical Trial. JAMA. 2017 Jun 27. 317 (24):2493-2501. [QxMD MEDLINE Link].
Doganay M, Kilic S, Yilmaz N. Long-term effects of extracorporeal magnetic innervations in the treatment of women with urinary incontinence: results of 3-year follow-up. Arch Gynecol Obstet. 2010 Jul. 282(1):49-53. [QxMD MEDLINE Link].
Burgio KL, Richter HE, Clements RH, Redden DT, Goode PS. Changes in urinary and fecal incontinence symptoms with weight loss surgery in morbidly obese women. Obstet Gynecol. 2007 Nov. 110(5):1034-40. [QxMD MEDLINE Link].
Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009 Jan 29. 360(5):481-90. [QxMD MEDLINE Link]. [Full Text].
Phelan S, Kanaya AM, Subak LL, et al. Weight Loss Prevents Urinary Incontinence in Women With Type 2 Diabetes: Results From the Look AHEAD Trial. J Urol. 2012 Jan 18. [QxMD MEDLINE Link].
[Guideline] Kobashi KC, Vasavada S, Bloschichak A, Hermanson L, Kaczmarek J, Kim SK, et al. Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023). J Urol. 2023 Jun. 209 (6):1091-1098. [QxMD MEDLINE Link]. [Full Text].
Labrie J, Berghmans BL, Fischer K, Milani AL, van der Wijk I, Smalbraak DJ, et al. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med. 2013 Sep 19. 369(12):1124-33. [QxMD MEDLINE Link].
Serati M, Bauer R, Cornu JN, Cattoni E, Braga A, Siesto G, et al. TVT-O for the Treatment of Pure Urodynamic Stress Incontinence: Efficacy, Adverse Effects, and Prognostic Factors at 5-Year Follow-up. Eur Urol. 2013 May. 63(5):872-8. [QxMD MEDLINE Link].
Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence. JAMA. 2018 Oct 23. 320 (16):1659-1669. [QxMD MEDLINE Link].
Liu X, Li T, Zhang J, Lin X, Wang W, Fan X, et al. Mesenchymal stem cell-based therapy for female stress urinary incontinence. Front Cell Dev Biol. 2023. 11:1007703. [QxMD MEDLINE Link]. [Full Text].
Chen YC, Lin PH, Jou YY, Lin VC. Surgical treatment for urinary incontinence after prostatectomy: A meta-analysis and systematic review. PLoS One. 2017. 12 (5):e0130867. [QxMD MEDLINE Link]. [Full Text].
Yafi FA, DeLay KJ, Stewart C, Chiang J, Sangkum P, Hellstrom WJ. Device survival following primary implantation of the AMS 800 artificial urinary sphincter for male stress urinary incontinence. J Urol. 2016 Sep 7. [QxMD MEDLINE Link].
Lightner DJ, Gomelsky A, Souter L, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment 2019. J Urol. 2019 Sep. 202 (3):558-563. [QxMD MEDLINE Link].
Morgan JL, O'Connell HE, McGuire EJ. Is intrinsic sphincter deficiency a complication of simple hysterectomy?. J Urol. 2000 Sep. 164(3 Pt 1):767-9. [QxMD MEDLINE Link].
Markland AD, Tangpricha V, Mark Beasley T, Vaughan CP, Richter HE, Burgio KL, et al. Comparing Vitamin D Supplementation Versus Placebo for Urgency Urinary Incontinence: A Pilot Study. J Am Geriatr Soc. 2018 Dec 21. [QxMD MEDLINE Link].
Arjmand M, Abbasi H, Behforouz A. The effect of vitamin D on urgent urinary incontinence in postmenopausal women. Int Urogynecol J. 2023 Feb 24. [QxMD MEDLINE Link].

Media Gallery

Urinary incontinence. Normal findings on urodynamic study of a 35-year-old white man. During the filling cystometrogram (CMG), there is absence of uninhibited detrusor contractions. Bladder compliance is normal. His maximum bladder capacity is 435 mL. During the pressure-flow study, his maximum flow rate (Qmax) is 25 mL/s and detrusor pressure at maximum flow rate (Pdet Qmax) is 50 cm H2O. The uroflow pattern is without abnormality, producing a bell-shaped curve without any abdominal straining. He voids to completion, and the postvoid residual urine is negligible.
Urinary incontinence. Urodynamic study revealing detrusor instability in a 75-year-old man with urge incontinence. Note the presence of multiple uninhibited detrusor contractions (phasic contractions) that is generating 40- to 75-cm H2O pressure during the filling cystometrogram (CMG). He also has small bladder capacity (81 mL), which is indicative of poorly compliant bladder.
Urinary incontinence. Urodynamic study revealing detrusor hyperreflexia in a 22-year-old woman with multiple sclerosis. Note the presence of multiple phasic contractions (uninhibited detrusor contractions) generating as much as 100 cm H2O pressure.
Urinary incontinence. Urodynamic recording of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) in a 55-year-old man. Note that during a pressure-flow study, his maximum flow rate (Qmax) is only 6 mL/s and detrusor pressure at maximum flow rate (Pdet Qmax) is very high at 101 cm H2O. He also has a small bladder capacity (50 mL) due to chronic bladder outlet obstruction. His flow curve is flat and "bread-loaf" in pattern, which is consistent with infravesical obstruction.
Urinary incontinence. Urodynamic study revealing detrusor sphincter dyssynergia in a 35-year-old woman with C5 spinal cord injury. Note the absence of uninhibited detrusor contractions during the filling cystometrogram (CMG). Typically, patients with cervical cord lesions manifest detrusor hyperreflexia. However, this patient is taking Ditropan XL. Thus, phasic contractions are suppressed. During the pressure-flow study, note the increase in amplitude of the electromyogram (EMG) coincident with detrusor contraction and voiding. Her uroflow rate is low (1 mL/s), detrusor pressure is high (42 cm H2O), and the EMG recording is elevated.
Urinary incontinence. Video-urodynamic study illustrating type III stress urinary incontinence (intrinsic sphincter deficiency [ISD]) in a 65-year-old woman. Static cystogram reveals obvious contrast leakage via the urethra during Valsalva maneuver. Urodynamic study records abdominal leak point pressure (ALPP) of 55 cm H2O, consistent with ISD.
A cystoscopic view of the bladder mucosa reveals shallow ulcerations and petechial hemorrhages, which are findings consistent with interstitial cystitis.
A cotton swab angle greater than 30° denotes urethral hypermobility. Figure 1 shows that the cotton swab at rest is zero with respect to the floor. Figure 2 shows that the cotton swab at stress is 45° with respect to the floor.
A squirt of urine is observed at the peak of an increase in intra-abdominal pressure in a supine patient
This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet.

of 10

Author

Sandip P Vasavada, MD Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Physician, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, Engineering and Urology Society, International Continence Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Axonics, BlueWind<br/>Received ownership interest from NDI Medical, LLC for review panel membership; Received consulting fee from allergan for speaking and teaching; Received consulting fee from medtronic for speaking and teaching; Received consulting fee from boston scientific for consulting. for: Oasis Consumer Healthcare.

Coauthor(s)

Oren Barat, BS MD Candidate, Northeast Ohio Medical University

Oren Barat, BS is a member of the following medical societies: American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

Giovanna Leone, BS MD Candidate, Northeast Ohio Medical University

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Additional Contributors

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Maude E Carmel, MD, FRCSC Fellow in Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic

Maude E Carmel, MD, FRCSC is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Peter MC DeBlieux, MD Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Farzeen Firoozi, MD Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation

Farzeen Firoozi, MD is a member of the following medical societies: American Medical Association and American Urological Association

Disclosure: Nothing to disclose.

Michael S Ingber, MD Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic

Disclosure: Nothing to disclose.

Shunaha Kim-Fine, MD Fellow in Female Pelvic Medicine and Reconstructive Surgery, Mayo Clinic

Disclosure: Nothing to disclose.

Christopher J Klingele, MD, MS Assistant Professor of Obstetrics and Gynecology, Mayo Medical School; Consultant, Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic

Disclosure: AMS - American Medical Systems Grant/research funds Multicenter research project on Miniarc pubovaginal sling for urinary incontinence

Nur-Ain Nadir, MD Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate School of Medicine

Nur-Ain Nadir, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Olufunmilayo Ogundele, MD Clinical Assistant Instructor, Staff Physician, Departments of Emergency and Internal Medicine, State University of New York Downstate, Kings County Hospital Center

Olufunmilayo Ogundele, MD is a member of the following medical societies: American Medical Association and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Kris Strohbehn, MD Professor of Obstetrics/Gynecology, Dartmouth Medical School; Director, Division of Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics/Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, and Society of Gynecologic Surgeons

Disclosure: Astellas Grant/research funds Investigator

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, and Society of Women in Urology

Disclosure: Nothing to disclose.